There are more than 3.8 million women with a history of breast cancer in the U.S., me included, and it is estimated that this year 30 percent of newly diagnosed cancers in women will be breast cancers. Each woman diagnosed with breast cancer will face many decisions at one of the most stressful times in her life, including the possibility of surgery to remove part or all her breast or breasts. For women who choose to undergo breast reconstruction surgery, several procedures are available, such as (i) autologous reconstruction, which uses the patient’s tissue, or (ii) implant reconstruction, which inserts a medical device. The decision to undergo breast reconstruction is highly personal to each woman, and to ensure the safest and least disruptive procedure, all options should be available without restriction.
There are varying procedures for an autologous reconstruction, where a patient’s natural tissue is transplanted from another part of her body. A traditional form of autologous reconstruction uses the tissue from the transverse rectus abdominis (TRAM) flap, but, for many women, this procedure has resulted in long-term disability, long hospitalizations, decreased strength, and complications such as hernia formation because it removes all or part of a woman’s core muscles. As breast reconstruction techniques made advancements, the advent of the DIEP flap autologous reconstruction procedure revolutionized reconstruction by allowing lifelong, natural tissue reconstruction without damaging muscle. DIEP flap reconstruction has led to significantly better patient outcomes, including reduced hospitalization, quicker recovery times, faster return to work, and better quality of life for patients.
Unfortunately, in January 2021, CMS eliminated code S2068 for deep inferior epigastric perforator (DIEP) flap breast reconstruction. The DIEP autologous reconstruction technique was previously differentiated from older, muscle-removing surgeries, like TRAM flap reconstruction, but CMS decided to combine all reconstructive flaps together, despite critical differences between the techniques. This change has spurred some commercial payers to stop reimbursing for the advanced reconstruction provided by the DIEP flap procedure, announcing that they will no longer differentiate between muscle-removing surgeries and surgeries that do not remove any muscle.1,2
From a patient-centered perspective, these two types of surgery could not be more different. DIEP surgery reconstructs a woman’s breast while preserving her strength as she plans her return to a full and productive life. TRAM surgery removes a woman’s core muscles and debilitates her for the remainder of her life. Because the muscle goes undisturbed, the DIEP flap is considered an improvement over its predecessor, the TRAM flap.
The unintended consequences of CMS’ decision are clear and dramatic: patients will no longer have access through insurance to the safer, advanced techniques that preserve their muscle and their function, and they will be forced to choose inferior reconstructive options that insurance would cover.
For this reason, I would strongly encourage you to write to your representatives and senator and encourage them to back senators Amy Klobuchar and Marsha Blackburn who are working to encourage CMS to reinstate code S2068 to ensure patients facing breast cancer continue to have access to the highest standard of breast reconstruction.
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